A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

Contact the client's caregiver to discuss the client's comment.

Review the medical record to see if the client has reported abuse in the past.

Report the suspected abuse to the nurse manager.

Restrict family members from visiting with the client.

Answer and Explanation

The Correct Answer is B

A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.

B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.

C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.

D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.

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Correct Answer is B

Explanation

A. "Communicate with personnel about the need for prophylaxis" is incorrect. While it is important to consider prophylaxis for those who may have been exposed to tuberculosis, the first priority is to minimize the risk of transmission from the client to others.

B. "Place a mask on the client" is correct. Placing a mask on the client is the first step in preventing the spread of tuberculosis. This helps contain respiratory droplets that could transmit the bacteria to others.

C. "Contact those who live with the client" is incorrect. While it is important to contact close contacts to assess their risk, this action comes after implementing infection control measures, such as placing a mask on the client.

D. "Notify the local health department" is incorrect. While the health department must be notified about a tuberculosis diagnosis, the immediate priority is to protect others from exposure by masking the client and using appropriate isolation precautions.

A. "This must be very frightening for you. Let's talk more about it." B. "What makes you think the staff is following you?" C. “Why do you feel the staff is the FBI?" D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

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A home health nurse is caring for an older adult client who lives with a family caregiver and has urinary incontinence. The client states, "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is collecting data from a client who was just diagnosed with tuberculosis. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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